Making data map-worthy—enhancing routine malaria data to support surveillance and mapping of Plasmodium falciparum anti-malarial resistance in a pre-elimination sub-Saharan African setting: a molecular and spatiotemporal epidemiology study

Abstract

Background Independent emergence and spread of artemisinin-resistant Plasmodium falciparum malaria have recently been confirmed in Africa, with molecular markers associated with artemisinin resistance increasingly detected. Surveillance to promptly detect and effectively respond to anti-malarial resistance is generally suboptimal in Africa, especially in low transmission settings where therapeutic efficacy studies are often not feasible due to recruitment challenges. However, these communities may be at higher risk of anti-malarial resistance. Methods From March 2018 to February 2020, a sequential mixed-methods study was conducted to evaluate the feasibility of the near-real-time linkage of individual patient anti-malarial resistance profiles with their case notifications and treatment response reports, and map these to fine scales in Nkomazi sub-district, Mpumalanga, a pre-elimination area in South Africa. Results Plasmodium falciparum molecular marker resistance profiles were linked to 55.1% (2636/4787) of notified malaria cases, 85% (2240/2636) of which were mapped to healthcare facility, ward and locality levels. Over time, linkage of individual malaria case demographic and molecular data increased to 75.1%. No artemisinin resistant validated/associated Kelch-13 mutations were detected in the 2385 PCR positive samples. Almost all 2812 samples assessed for lumefantrine susceptibility carried the wildtype mdr86ASN and crt76LYS alleles, potentially associated with decreased lumefantrine susceptibility. Conclusion Routine near-real-time mapping of molecular markers associated with anti-malarial drug resistance on a fine spatial scale provides a rapid and efficient early warning system for emerging resistance. The lessons learnt here could inform scale-up to provincial, national and regional malaria elimination programmes, and may be relevant for other antimicrobial resistance surveillance.

Factors Affecting Integration of an Early Warning System for Antimalarial Drug Resistance within a Routine Surveillance System in a Pre-elimination Setting in Sub-Saharan Africa

“…Further quantitative results are reported elsewhere. [12] A total of 46 healthcare workers participated in five separate FGDs, with group sizes ranging from 8 -12 participants. Of the participants, 32 were nurses (including professional nurses, occupational nurses, and assistant nurses), and 14 were environmental health officers who worked as health promoters or malaria case investigators, data clerks, data capturers and surveillance officers.…”

“…Previous evidence has shown that integrating antimalarial molecular markers using a routine malaria notification system is feasible in sub-Saharan African settings. [12] However, little is known about the barriers and enhancers to integrating molecular markers of resistance within the routine malaria surveillance system.…”

“…[18] 'Making Data Mapworthy' was a quantitative sub-study linked to the SS4ME pilot that evaluated the feasibility of integrating molecular resistance markers into the routine malaria surveillance system using coverage, accuracy and linkage of malaria cases in near real-time. [12] However, these metrics alone could not fully examine the flow of data, or users' practices and perceptions. Here, factors influencing the flow, quality and linkage of malaria notification data and associated molecular resistance markers from different reporting levels are investigated to inform the enhancement and sustainability of this integrated early warning system for antimalarial resistance.…”

“…This called for increased programmatic support and training, and with time, the study observed improvement of barcoded mRDT samples received at the NICD laboratory from 19% in the first quarter to 85% in the final quarter, reflecting gradual acceptance and adaptability. [12] . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.…”

“…Despite the slow start, the overall outcomes of the number and quality of samples for molecular marking increased, for instance, the overall linkage of the molecular resistance markers and case notification rose from 51% in the first quarter to the highest of 75.1% in the third quarter, with participants noting how the activities strengthened the routine antimalarial resistance surveillance. [12] . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.…”